Healthcare Provider Details

I. General information

NPI: 1285001842
Provider Name (Legal Business Name): MR. TREVIS LEE TREVINO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2015
Last Update Date: 08/13/2022
Certification Date: 08/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1851 44TH ST SW STE A
WYOMING MI
49519-6440
US

IV. Provider business mailing address

915 FAIRMOUNT ST SE
GRAND RAPIDS MI
49506-1555
US

V. Phone/Fax

Practice location:
  • Phone: 616-538-4400
  • Fax:
Mailing address:
  • Phone: 310-625-9373
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number3019283855
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number1849503021
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberTT37598187
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code2083S0010X
TaxonomySports Medicine (Preventive Medicine) Physician
License NumberTT37598187
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code2083S0010X
TaxonomySports Medicine (Preventive Medicine) Physician
License NumberT615802497876
License Number StateMI
# 6
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberT615802497876
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: